Massive Transfusion Protocol

Reviewed and revised 10 March 2014


Massive transfusion is defined as

  • replacement of >1 blood volume in 24 hours, or
  • >50% of blood volume in 4 hours (adult blood volume is approximately 70 mL/kg), or
  • in children:  transfusion of >40 mL/kg (blood volume in children over 1 month old is approximately 80 mL/kg)

A Massive Transfusion Protocol should be used in critically bleeding patients anticipated to require massive transfusion


  • early recognition of blood loss
  • maintenance of tissue perfusion and oxygenation by restoration of blood volume and haemoglobin (Hb)
  • arrest of bleeding in combination with use of early surgical or radiological intervention, and
  • judicious use of blood component therapy to correct coagulopathy


  • Check these parameters early and frequently (e.g. every 30-60 minutes while massive transfusion is ongoing)
ParametersValues to aim for
Temperature>35 °C
Acid-base statuspH >7.2, base excess <–6, lactate <4 mmol/L
Ionised calcium (Ca)>1.1 mmol/L
Haemoglobin (Hb)This should not be used alone as transfusion trigger; and, should be interpreted in context with haemodynamic status, organ & tissue perfusion.
Platelet (Plt)≥ 50 x 10^9 /L (>100 x 10^9 if head injury/ intracranial haemorrhage)
PT/APTT≤ 1.5x of normal
Fibrinogen≥ 1.0 g/L



Risks and complications of large volume resuscitation with blood products

  • volume overload (careful monitoring of filling pressures, response to volume, diuresis etc)
  • over-transfusion (monitor Hb regularly, titrate according to needs)
  • hypothermia (monitor temp, use fluid warmers and other measures to reduce heat loss)
  • dilutional coagulopathy of clotting factors and platelets (regular and early monitoring of coagulation, involvement of haematology for replacement therapy )
  • Transfusion related acute lung injury (consider use of filters, leukodepletion)
  • excessive citrate causing metabolic alkalosis and hypocalcaemia (monitor pH and ionised calcium, replace calcium as necessary)
  • hyperkalaemia (use of younger blood, monitor regularly, may require specific therapy)
  • disease transmission (use of products only on a needed basis only, standard blood banking precautions etc)

If uncross-matched / O neg blood

  • Haemolytic disease of newborn if RhD mismatch
  • Difficulty with cross-matching future blood product
  • Difficulty with matching solid organs

Logistical issues

  • distractions resulting in not controlling source of haemorrhage, and
  • risks of hurried cross-checking and incompatibility (allocation of sufficient resources and personnel, standard programs in place to facilitate process and anticipate needs)
  • other problems including loss of identity, crossmatching issues, loss of baseline haematological information etc)

Usual transfusion reactions and problems

  • Acute / delayed haemolytic transfusion reaction
  • Non-febrile haemolytic transfusion reaction
  • Bacterial / viral infection
  • Anaphylaxis if IgA deficient
  • GVHD
  • Storage lesion effects

CCC Transfusion Series

Blood Products

Cryoprecipitate, Fresh Frozen Plasma (FFP), PlateletsRed Cells (RBCs)

Concentrates: Prothrombinex, Factor VIIa, Fibrinogen Concentrate


Rivaroxaban / Apixaban / Enoxaparin: Andexanet Alfa, Rivaroxaban and Bleeding

DabigatranIdarucuzimabDabigatran and bleeding


WarfarinVitamin K / FFP / PTx, Warfarin Reversal, Warfarin Toxicity


Coagulation StudiesTEG / ROTEM (Thromboelastography)Platelet function assays

General Topics

Acute Coagulopathy of TraumaBlood BankBlood conservation strategiesBlood Product Compatibilities, Blood transfusion risksDisseminated Intravascular CoagulationMassive blood lossMassive transfusion protocol (MTP)Modifications to blood components,Procedures and CoagulopathyStorage LesionsTRALITransfusion Literature Summaries, Transfusion Reactions



CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC


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